Side Event: Drug use and COVID-19: public health challenges and priorities at the time of the pandemic and beyond

Side event organized by the World Health Organization (WHO)

Mariângela Simão (WHO Assistant Director-General, Access to Medicines and Health Products):

I am pleased to welcome you all to this important side event on COVID-19, and to discuss the provision of essential services related to drugs during the pandemic. Throughout the pandemic, WHO emphasised the need for uninterrupted access to drug treatment and services, as well as other health services. Yet as many as 77% of countries are reporting interruptions of health services during the last year. As a result, services such as harm reduction and drug treatment have been impacted – some have shit down, which has left people without access to life-saving services at a time, further exacerbating challenges. Many countries are also reporting stock-outs of essential medicines, as well as disruptions of supplies of opioids. But in spite of the challenges, we also see new opportunities and initiatives that have come up to ensure continuity and even to improve essential health services for people who use drugs. We have also seen new psychoactive drugs entering the illicit market, so we must also remain vigilant. Access to medicines for pain management and palliative care remains an urgent priority, and WHO is developing guidelines to ensure that these medicines are available where needed.

Soumya Swaminathan (WHO Chief Scientist)

I will provide a quick overview of the current situation. Globally, after a reduction in new cases in the first few weeks of the year – we are now seeing an increase, especially in Asia and the EMRO region. There were 75,597 recorded deaths last week. This may be because people are letting down their guard, economies are opening back up, etc. The pandemic has had huge impacts on health, but also beyond health – the global economy was estimated to contract by 4.3% in 2020, with knock-on effects on world poverty, hunger and the Sustainable Development Goals (SDGs). The Human Development Index will take a significant ‘hit’ for 2020. Health systems are impacted by lacks of stock, the burden on workers, disruptions and the huge levels of stress. WHO’s data from 2020 show that all kinds of essential health services were partially or completely disrupted by COVID-19.

WHO recognised that this needed a new, global response and set-up ACT-A nearly one year ago to accelerate the development of, and equitable access to, new tools and technologies (diagnostics, vaccines, etc). Diagnostic tests are often being overlooked, but will remain important in 2021 to improve surveillance and target interventions. There has been a ‘rich pipeline’ of new tests in such a short space of time. There is a great deal of research being done – there are thousands of trials currently underway, but with the risk of being fragmented. WHO has also continued to review the therapeutic responses available. WHO’s “COVAX” project shows that there are 87 candidate vaccines undergoing clinical development – 20 of which are in the later stages of the process. SAGE has recommended four vaccines, and guidelines on how to prioritise people for vaccinations. WHO also continues to monitor new variants of concern – especially those which might impact on transmission or vaccine / diagnostic effectiveness. The COVAX facility has achieved many ‘world firsts’ in the last 12 months – yet there continue to be major issues with vaccine supply and equitable access, and some countries are still awaiting their first doses even for frontline workers, etc.

Devora Kestel (Director, WHO Department of Mental Health and Substance Use)

Prior to COVID-19, there were already many challenges facing mental health and substance use services – and when the pandemic came, these all became even heavier burdens for the field to carry. For example, the isolation caused by ‘stay at home’ disorders has played a role. We also now learn more about the post-acute / long-haul impacts of COVID-19 – including fatigue, depression, substance use, post-traumatic stress disorder, stigma, and other neurological complications. On substance use more specifically, we have evidence of the impact of the pandemic on substance use disorders, along with the disruptions to services – which has the potential to be life-threatening. In some cases, alternative services are functioning or have adapted, but we need more time to understand the impact of these. Preliminary data also suggest the increase globally in levels of things like online gambling during lockdown. WHO have been working to make the evidence available through the proper channels – ensuring communication to the general public as well as for professionals. This includes WHO guidance (2020) on maintaining essential health services, which state that services should be continued such as residential services, services for opioid overdoses, substance withdrawal, harm reduction and psychosocial interventions, opioid agonist maintenance treatment (OAMT), etc. This also includes provisions for digital / home care. Yet 93% of countries assess reported some disruption of mental health and substance use services: 27% reported complete disruption of OAMT. The three policy actions sent to governments are to allocate resources, maintain essential services, and strengthen the monitoring so we can see what is happening, and why.

Meg Doherty (Director, WHO Department of Global HIV, Hepatitis and STI Programmes)

People who inject drugs are at high risk of mortality and morbidity through overdose and infectious diseases such as HIV, TB and viral hepatitis. Yet less than 1% of them have sufficient access to harm reduction services, and COVID may well have made this even worse.

WHO guidance states that harm reduction services are essential, life-saving services that must be continued during the pandemic, including: needle and syringe programmes, OAMT, naloxone to manage opioid overdose, and testing and treatment of HIV, TB and viral hepatitis. WHO guidelines have also long called for the decentralisation of care – such as provision outside of central healthcare facilities, with rapid treatment onset and clinical visits every 3–6 months, with community health workers able to play a role. However, research from the World Hepatitis Alliance indicate that 23% of people could not continue their treatment during COVID lockdowns, and 65% avoiding going to health care facilities due to fear of COVID-19.

Harm Reduction International have also released data on access to OAMT during COVID-19, and this showed that 47 countries expanded take-home provisions, while 23 looked for other ways to improve accessibility (home deliveries, etc). This shows that adaptations were possible and worked in many settings. In South-East Asia, services were relocated out of facilities, tasks were shifted to the community, prescription periods were extended, and eligibility criteria were adapted to improve access to ART. In Ukraine, there was a move to alternative models of dispensing for ART, including through social workers and mobile teams. WHO has identified common elements from these adaptations: the protection of service providers and clients, multi-month dispensing, community-led initiatives, remote and online platforms, and integration with other services.

In prisons and closed settings, the evidence is that COVID-19 is higher and that many people are living with key co-morbidities. Prison populations are considered as a priority for vaccination by WHO SAGE – as highlighted by the Health in Prison Project (HIPP) alongside Penal Reform International. Desk reviews show there are more than 500,000 cases of COVID-19 in prison, and higher infection rates and death rates than in the general population. WHO guidance (HIPP) is that people living in prison should be included in national vaccination plans against COVID-19, on the basis of their increased vulnerability and the principle of equivalence. People living in prison should have a guaranteed right to be informed about how to protect themselves from COVID-19 by immunization and other measures.

To conclude, harm reduction services are essential and pivotal in reaching people who use drugs. The COVID-19 adaptations in delivery of harm reduction and treatment for HIV and hepatitis can increase access to services and should remain in place after the pandemic. Greater involvement of the community of people who use drugs is crucial to increase access and retention in services. Harm reduction staff can provide accurate information on prevention as well as on vaccination. Harm reduction sites could be considered to provide vaccination to their clients. Prisons should be part of national vaccination plans.

Question 1:  At the CND this week, there is some debate on resolutions about whether drug services can be described as “essential”. What would the WHO’s advice be to Member States on this issue?

Devora Kestel: Of course, we are in favour of this inclusion as “essential”. WHO came up with their recommendations after careful assessment of the evidence, and identified which components were essential for people with drug use problems. So for us, it is very clear and we can share the link to that guidance.

Meg Doherty: In our guidance across the WHO, harm reduction and drug services are considered to be essential and life-saving. So you can find from all of our recommendations and guidelines and strategies that these are considered as “essential”, and I hope that this helps with the debates this week.

Soumya Swaminathan: For WHO to recommend something as “essential”, this means that it has gone through a robust process of evidence review and analysis – so hopefully the guidance has weight in the debates. From our side, if we consider it as “essential” then it means exactly that from a health point of view.

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